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Adirondack Economic Development Corporation MicroLoan/IRP Program

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					                     Adirondack Economic Development Corporation
                          MicroLoan/IRP Program Application
Please complete the following information. We will review your application form and any additional information that you
provide to determine if you are eligible for the AEDC MicroLoan/IRP Program. If you are eligible, we will schedule a
meeting with you to discuss your loan request. We may ask for more specific information regarding your business and loan
request.

PLEASE NOTE: **There is an application fee of $100.00 on IRP Program Application.

BUSINESS INFORMATION (Use additional paper if necessary)
Owners:
___________________________________________________________________________________________________________________________________

Name(s)                          SS#                DOB                % Ownership        Home Address                      City/State/Zip



___________________________________________________________________________________________________________________________________

Name(s)                          SS#                DOB                % Ownership        Home Address                      City/State/Zip



Business Ph: (      )                    Home Ph: (       )                   Fax: (       )                Email: _________________

Business Name: ____________________________________________________________________________________

Type of Business Organization: o Not established o Sole Proprietorship o Partnership                 o S Corp.    o C Corp. o LLC


Business Location (if different): ______________________________________________________________________
                                           Street                                         City                   County                Zip
Describe Type of Business (Product or Service):__________________________________________________________
_________________________________________________________________________________________________

Date Business Established:                                    Current Number of Employees: FT                      PT

Federal Tax ID Number: ________________                       Projected first year sales (per cash flow projections) $__________

Personal/business judgments, liens, unsettled lawsuits or major disputes? o YES o NO
    If YES, Please Explain: ____________________________________________________________________
__________________________________________________________________________________________

Has the business, or any principals of the business, been involved in bankruptcy or insolvency proceedings?
   o YES o NO If YES, Please explain: ______________________________________________________
Have you attended an AEDC “Small Business Institute” classes? o Yes                         o No
Have you completed a Business Plan?      o Yes        o No (If so, please submit a copy of the Business Plan with this Application.)
When/by whom was Business Plan prepared?                                        Phone:

Are you are working with a counselor at the Small Business Development Center? o Yes o No
Name of Counselor:____________________________________________ Phone Number:_______________

Are you working with a counselor at the Service Corps of Retired Executives o Yes o No
Name of Counselor:____________________________________________ Phone Number:_______________

INFORMATION
Total loan request: $              Break down use: Working Capital $                       Equipment $                    Inventory $

Real Estate $                     Supplies $
Personal cash available to invest in business/project: $                              Source:

Personal cash already spent to start up business $

What Collateral will you pledge:       House         Auto    Property      Machinery/Equipment        Inventory Other:

What bank have you contacted for financing?

Name of Banker:                                                                        Telephone #:

CERTIFICATIONS: Please read the following and sign the Application Form below. All owners, officers, or
partners must sign this application. If you have any questions, please call (518) 891-5523.
    This is an Equal Opportunity Program. USDA prohibits discrimination in all its programs and activities on the
    basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation or marital or
    family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative
    means for communication of program information (Braille, large print, audiotape, etc) should contact USDA’s
    TARGET center at 202-720-2600(voice and TDD). To file a complaint of discrimination write: USDA, Director,
    Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington DC 20250-
    9410 or call 202-720-5964(voice and TDD).
The information in this Loan Application is provided for the purpose of applying for funds under the MicroLoan/IRP Program. The
information is accurate to the best of my knowledge. I understand that personal and/or business information may be requested
pursuant to this Loan Application and I hereby give my consent for such information to be provided to Adirondack Economic
Development Corporation. I also understand that the Adirondack Economic Development Corp. retains the sole decision as to
whether this Loan Application is approved, disapproved, or modified. It is my right to accept or decline the loan amount, rate, and
terms approved by the Program.

I AUTHORIZE Adirondack Economic Development Corporation (AEDC) to obtain a credit report on me through the credit
reporting agency of its choice. If an adverse credit decision is made due totally or partly to the information on the credit report,
AEDC will give me a copy of the credit report, a summary of my rights under the Fair Credit Reporting Act, and the source of the
credit report so that I may contact them if I wish.

I UNDERSTAND THAT ALL INFORMATION I SUBMIT TO AEDC’s MICROLOAN/IRP PROGRAM WILL BE KEPT
ON FILE FOR A MAXIMUM OF 60 DAYS. IF I DO NOT REQUEST THE RETURN OF THIS INFORMATION IT
WILL BE SHREADED AND DISPOSED OF.


Name (Printed):                                                 Name (Printed):

Signature:                                                      Signature:

Date:                                                           Date:

“The following information is requested by the Federal Government in order to monitor compliance with Federal Laws prohibiting
discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are
encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way.
However, if you choose not to furnish it, we are required to note the race/national origin of individual applicants on the basis of
visual observation or surname.”
Ethnicity:
Hispanic or Latino_____
Not Hispanic or Latino_____
Race: (Mark one of more)
White_____ Black or African American_____
American Indian/Alaska Native_____          Asian_____
Native Hawaiian or Other Pacific Islander_____
Gender: Male_____ Female_____
We also need the following for reporting purposes: Your combined household income as of today is: Yearly: $________How many
people in your household:____
Veteran status:  not a veteran  Vietnam-era veteran  other veteran  disabled veteran
Business ownership:  Female 100%           Female 51%           Male 100%  Male 51%             Minority 51% or greater


     Adirondack Economic Development Corporation, PO Box 747, 67 Main Street, Suite 200, Saranac Lake, NY 12983 Ph (518) 891-5523
                                      Telecommunication Services for the Deaf: 1-800-662-1220
                        A business plan is required to effectively evaluate and process your loan request.
                        Please contact our staff to schedule an appointment or meet contacts in your area.

                                     AEDC Business Plan Outline/Checklist
      Adirondack Economic Development Corporation, PO Box 747, 67 Main Street, Suite 200, Saranac Lake, NY 12983
                       For more information please contact our office at Toll Free 1-888-243-2332


I. Products & Services
   o List all products and services (menu, order form, etc.)
   o Include copies of special patents, copyrights, and/or permits necessary to provide this product/service
   o How are you unique or better than the competition?
   o List suppliers and their terms of payment
   o Manufacturing Process: If applies

II. Market Analysis
   o Target Market (define your niche or targeted market): Current & prospective
   (List of current customers; provide survey of potential clients, letters of intent)
   o Competition: Name, Address

III. Marketing Strategy
   o Pricing Policy: (include price list if you have)
   o Discounts: To whom, how much, what do they have to do to get the discount
   o Credit Policy: Lay-a-way, 6 months same as cash, 50% up front, cash only, credit cards?
   o Collection: What do you do if someone does not pay?
   o Methods of selling: Where, How often, When, How much does it cost - Provide samples if have

IV. Management Plan
   o Copy of all licenses and permits (vendor’s lic., articles of incorp., ptnrship agreement, reg. of name)
   o Resumes of owners and/or key personnel
   o Copy insurance coverage (in business, proof of coverage - start up, show quote.)
   o Copy Rental agreement (if applies, do not need if working from your home)
   o Goals for loan period, including jobs created
   o Technical & professional assistance: name, business, address, phone (acctnt., attny., ins. agent and banker)
   o Sample of brochure, business card, employee guidelines or other management forms or information

V. Financial Data
   o 3 references (personal or business)
   o Current personal financial statement (<30 days old)
   o Last 3 years personal tax returns
   o Last 3 years business tax returns (or as applies) Must provide if purchasing existing business
   o Business Balance Sheet (within the last 30 days)
   o Interim Profit & Loss statements, monthly
   o Last 3 months Business and Personal Bank Statements
   o Accounts receivable & accounts payable aging report
   o 1 year, by month, cash flow projections with assumption statements
   o Source & Use Statement (provide back up for numbers, ad, quote, etc.)



    Adirondack Economic Development Corporation, PO Box 747, 67 Main Street, Suite 200, Saranac Lake, NY 12983 Ph (518) 891-5523
            FOR ASSISTANCE IN COMPLETING A BUSINESS PLAN CONTACT:

Adirondack Economic Development Corporation:         (518) 891-5523

Small Business Development Center:           (518) 564-2042 Plattsburgh
                                                    (315) 386-7312 Canton
                                                    (518) 453-9567 Albany
                                                    (315) 498-6070 Syracuse
                                                    (315) 792-7546 Utica
                                                    (315) 782-9262 Watertown

Entrepreneur Center of the Mohawk Valley:            (315) 733-9848 Dr. Patricia Laino


        FOR ASSISTANCE IN COMPLETING THE LOAN APPLICATION CONTACT:

Adirondack Economic Development Corporation:         (518) 891-5523


                         STATE AND LOCAL PERMITS AND LICENSES

Local requirements can be determined by contacting village, town, city or county clerks; state
requirements can be found by calling OBPRA at (800) 342-3464.


                       FILE WITH THE NYS SALES TAX DEPARTMENT

To operate as a business in New York State you are required to register as a vendor with the Tax
Department; forms can be obtained by calling (800) 462-8100.


                              FEDERAL IDENTIFICATION NUMBER

An Employer Identification Number is required by the Internal Revenue Service if you will have one or
more employees, or if not an employer, if your business is a partnership or a corporation; forms can be
obtained by calling (800) 829-3676.


                       FILE A CERTIFICATE OF BUSINESS NAME (DBA)

Register a “Certificate of Doing Business Under an Assumed Name” with the County Clerk in the county
where the business will be conducted; should be prepared and registered in triplicate – one for the county
clerk, one for your bank, one for your records.

				
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Description: Adirondack Economic Development Corporation MicroLoan/IRP Program Application Please complete the following information. We will review your application form and any ...